White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MG Device Plcmnt w/ Mammo Guide Left

Facility

$1,175.00

Service Code	HCPCS 19281
Hospital Charge Code	3641063
Hospital Revenue Code	320
Min. Negotiated Rate	$105.75
Max. Negotiated Rate	$3,507.10
Rate for Payer: Amerigroup CHIP/Medicaid	$105.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$1,018.72
Rate for Payer: BCBS of TX Blue Essentials	$1,220.02
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$799.00
Rate for Payer: Cash Price	$799.00
Rate for Payer: Cash Price	$799.00
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$846.00
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$846.00
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
Rate for Payer: Multiplan Auto	$763.75
Rate for Payer: Multiplan Commercial	$763.75
Rate for Payer: Multiplan Workers Comp	$763.75
Rate for Payer: Parkland Medicaid	$846.00
Rate for Payer: Scott and White EPO/PPO	$118.49
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$846.00
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

MG Device Plcmnt w/ Mammo Guide Left

Facility

$1,175.00

Service Code	HCPCS 19281
Hospital Charge Code	3641063
Hospital Revenue Code	320
Rate for Payer: Cash Price	$799.00

MG Device Plcmnt w/ Mammo Guide Right

Facility

$1,175.00

Service Code	HCPCS 19281
Hospital Charge Code	3641061
Hospital Revenue Code	320
Rate for Payer: Cash Price	$799.00

MG Device Plcmnt w/ Mammo Guide Right

Facility

$1,175.00

Service Code	HCPCS 19281
Hospital Charge Code	3641061
Hospital Revenue Code	320
Min. Negotiated Rate	$105.75
Max. Negotiated Rate	$3,507.10
Rate for Payer: Amerigroup CHIP/Medicaid	$105.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$1,018.72
Rate for Payer: BCBS of TX Blue Essentials	$1,220.02
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$1,537.23
Rate for Payer: Cash Price	$799.00
Rate for Payer: Cash Price	$799.00
Rate for Payer: Cash Price	$799.00
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$846.00
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$846.00
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
Rate for Payer: Multiplan Auto	$763.75
Rate for Payer: Multiplan Commercial	$763.75
Rate for Payer: Multiplan Workers Comp	$763.75
Rate for Payer: Parkland Medicaid	$846.00
Rate for Payer: Scott and White EPO/PPO	$118.49
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$846.00
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

MG Mammo Digital Diagnostic Bilat

Facility

$672.00

Service Code	HCPCS 77066
Hospital Charge Code	3641094
Hospital Revenue Code	401
Min. Negotiated Rate	$60.48
Max. Negotiated Rate	$483.84
Rate for Payer: Amerigroup CHIP/Medicaid	$60.48
Rate for Payer: BCBS of TX Blue Advantage	$198.61
Rate for Payer: BCBS of TX Blue Essentials	$238.33
Rate for Payer: BCBS of TX PPO	$266.02
Rate for Payer: Cash Price	$456.96
Rate for Payer: Cash Price	$456.96
Rate for Payer: Cigna Medicaid	$483.84
Rate for Payer: Molina CHIP/Medicaid	$483.84
Rate for Payer: Multiplan Auto	$436.80
Rate for Payer: Multiplan Commercial	$436.80
Rate for Payer: Multiplan Workers Comp	$436.80
Rate for Payer: Parkland Medicaid	$483.84
Rate for Payer: Scott and White EPO/PPO	$195.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$483.84
Rate for Payer: Superior Health Plan EPO	$91.39

MG Mammo Digital Diagnostic Bilat

Facility

$672.00

Service Code	HCPCS 77066
Hospital Charge Code	3641094
Hospital Revenue Code	401
Rate for Payer: Cash Price	$456.96

MG Mammo Digital Diagnostic Right

Facility

$483.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	3641096
Hospital Revenue Code	401
Rate for Payer: Cash Price	$328.44

MG Mammo Digital Diagnostic Right

Facility

$483.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	3641096
Hospital Revenue Code	401
Min. Negotiated Rate	$43.47
Max. Negotiated Rate	$347.76
Rate for Payer: Amerigroup CHIP/Medicaid	$43.47
Rate for Payer: BCBS of TX Blue Advantage	$155.20
Rate for Payer: BCBS of TX Blue Essentials	$186.24
Rate for Payer: BCBS of TX PPO	$207.87
Rate for Payer: Cash Price	$328.44
Rate for Payer: Cash Price	$328.44
Rate for Payer: Cigna Medicaid	$347.76
Rate for Payer: Molina CHIP/Medicaid	$347.76
Rate for Payer: Multiplan Auto	$313.95
Rate for Payer: Multiplan Commercial	$313.95
Rate for Payer: Multiplan Workers Comp	$313.95
Rate for Payer: Parkland Medicaid	$347.76
Rate for Payer: Scott and White EPO/PPO	$241.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$347.76
Rate for Payer: Superior Health Plan EPO	$65.69

MG Mammo Digital Screening Bilateral

Facility

$512.00

Service Code	HCPCS 77067
Hospital Charge Code	3620241
Hospital Revenue Code	403
Rate for Payer: Cash Price	$348.16

MG Mammo Digital Screening Bilateral

Facility

$512.00

Service Code	HCPCS 77067
Hospital Charge Code	3620241
Hospital Revenue Code	403
Min. Negotiated Rate	$46.08
Max. Negotiated Rate	$368.64
Rate for Payer: Amerigroup CHIP/Medicaid	$46.08
Rate for Payer: BCBS of TX Blue Advantage	$164.13
Rate for Payer: BCBS of TX Blue Essentials	$196.95
Rate for Payer: BCBS of TX PPO	$219.83
Rate for Payer: Cash Price	$348.16
Rate for Payer: Cash Price	$348.16
Rate for Payer: Cigna Medicaid	$368.64
Rate for Payer: Molina CHIP/Medicaid	$368.64
Rate for Payer: Multiplan Auto	$332.80
Rate for Payer: Multiplan Commercial	$332.80
Rate for Payer: Multiplan Workers Comp	$332.80
Rate for Payer: Parkland Medicaid	$368.64
Rate for Payer: Scott and White EPO/PPO	$158.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.64
Rate for Payer: Superior Health Plan EPO	$69.63

Mica burr 2 X 12mm sterile mica

Facility

$2,238.22

Hospital Charge Code	993403
Hospital Revenue Code	272
Min. Negotiated Rate	$201.44
Max. Negotiated Rate	$1,611.52
Rate for Payer: Amerigroup CHIP/Medicaid	$201.44
Rate for Payer: BCBS of TX Blue Advantage	$671.47
Rate for Payer: BCBS of TX Blue Essentials	$805.76
Rate for Payer: BCBS of TX PPO	$895.29
Rate for Payer: Cash Price	$1,521.99
Rate for Payer: Cigna Medicaid	$1,611.52
Rate for Payer: Molina CHIP/Medicaid	$1,611.52
Rate for Payer: Multiplan Auto	$1,454.84
Rate for Payer: Multiplan Commercial	$1,454.84
Rate for Payer: Multiplan Workers Comp	$1,454.84
Rate for Payer: Parkland Medicaid	$1,611.52
Rate for Payer: Scott and White EPO/PPO	$1,119.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,611.52
Rate for Payer: Superior Health Plan EPO	$304.40

Mica burr 2 X 12mm sterile mica

Facility

$2,238.22

Hospital Charge Code	993403
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,521.99

Mica burr 2 X 20mm sterile mica

Facility

$2,238.22

Hospital Charge Code	993404
Hospital Revenue Code	272
Min. Negotiated Rate	$201.44
Max. Negotiated Rate	$1,611.52
Rate for Payer: Amerigroup CHIP/Medicaid	$201.44
Rate for Payer: BCBS of TX Blue Advantage	$671.47
Rate for Payer: BCBS of TX Blue Essentials	$805.76
Rate for Payer: BCBS of TX PPO	$895.29
Rate for Payer: Cash Price	$1,521.99
Rate for Payer: Cigna Medicaid	$1,611.52
Rate for Payer: Molina CHIP/Medicaid	$1,611.52
Rate for Payer: Multiplan Auto	$1,454.84
Rate for Payer: Multiplan Commercial	$1,454.84
Rate for Payer: Multiplan Workers Comp	$1,454.84
Rate for Payer: Parkland Medicaid	$1,611.52
Rate for Payer: Scott and White EPO/PPO	$1,119.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,611.52
Rate for Payer: Superior Health Plan EPO	$304.40

Mica burr 2 X 20mm sterile mica

Facility

$2,238.22

Hospital Charge Code	993404
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,521.99

MICA FIRST MET TRANSLATOR STERILE MICA

Facility

$1,048.19

Hospital Charge Code	993134
Hospital Revenue Code	270
Min. Negotiated Rate	$94.34
Max. Negotiated Rate	$754.70
Rate for Payer: Amerigroup CHIP/Medicaid	$94.34
Rate for Payer: BCBS of TX Blue Advantage	$314.46
Rate for Payer: BCBS of TX Blue Essentials	$377.35
Rate for Payer: BCBS of TX PPO	$419.28
Rate for Payer: Cash Price	$712.77
Rate for Payer: Cigna Medicaid	$754.70
Rate for Payer: Molina CHIP/Medicaid	$754.70
Rate for Payer: Multiplan Auto	$681.32
Rate for Payer: Multiplan Commercial	$681.32
Rate for Payer: Multiplan Workers Comp	$681.32
Rate for Payer: Parkland Medicaid	$754.70
Rate for Payer: Scott and White EPO/PPO	$524.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$754.70
Rate for Payer: Superior Health Plan EPO	$142.55

MICA FIRST MET TRANSLATOR STERILE MICA

Facility

$1,048.19

Hospital Charge Code	993134
Hospital Revenue Code	270
Rate for Payer: Cash Price	$712.77

micafungin 100 mg IV Inj

Facility

$128.00

Service Code	HCPCS J2248
Hospital Charge Code	77700522
Hospital Revenue Code	636
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$2.71
Rate for Payer: BCBS of TX Blue Essentials	$3.25
Rate for Payer: BCBS of TX PPO	$3.61
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

micafungin 100 mg IV Inj

Facility

$128.00

Service Code	HCPCS J2248
Hospital Charge Code	77700522
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

Mica wedge burr 3.1 X 13mm sterile mica

Facility

$2,238.22

Service Code	HCPCS C1713
Hospital Charge Code	993405
Hospital Revenue Code	278
Min. Negotiated Rate	$201.44
Max. Negotiated Rate	$1,611.52
Rate for Payer: Amerigroup CHIP/Medicaid	$201.44
Rate for Payer: BCBS of TX Blue Advantage	$671.47
Rate for Payer: BCBS of TX Blue Essentials	$805.76
Rate for Payer: BCBS of TX PPO	$895.29
Rate for Payer: Cash Price	$1,521.99
Rate for Payer: Cigna Medicaid	$1,611.52
Rate for Payer: Molina CHIP/Medicaid	$1,611.52
Rate for Payer: Multiplan Auto	$1,119.11
Rate for Payer: Multiplan Commercial	$1,119.11
Rate for Payer: Multiplan Workers Comp	$1,119.11
Rate for Payer: Parkland Medicaid	$1,611.52
Rate for Payer: Scott and White EPO/PPO	$1,119.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,611.52
Rate for Payer: Superior Health Plan EPO	$304.40

Mica wedge burr 3.1 X 13mm sterile mica

Facility

$2,238.22

Service Code	HCPCS C1713
Hospital Charge Code	993405
Hospital Revenue Code	278
Min. Negotiated Rate	$559.55
Max. Negotiated Rate	$1,119.11
Rate for Payer: Cash Price	$1,521.99
Rate for Payer: Cigna Commercial	$559.55
Rate for Payer: Multiplan Auto	$1,119.11
Rate for Payer: Multiplan Commercial	$1,119.11
Rate for Payer: Multiplan Workers Comp	$1,119.11
Rate for Payer: Scott and White EPO/PPO	$1,119.11

miconazole 2% Cream 30 g

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77701199
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

miconazole 2% Cream 30 g

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77701199
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

Microfiber Mop Cover With Pocket 8 / Bag 15 / Ca

Facility

$86.87

Hospital Charge Code	993578
Hospital Revenue Code	272
Min. Negotiated Rate	$7.82
Max. Negotiated Rate	$62.55
Rate for Payer: Amerigroup CHIP/Medicaid	$7.82
Rate for Payer: BCBS of TX Blue Advantage	$26.06
Rate for Payer: BCBS of TX Blue Essentials	$31.27
Rate for Payer: BCBS of TX PPO	$34.75
Rate for Payer: Cash Price	$59.07
Rate for Payer: Cigna Medicaid	$62.55
Rate for Payer: Molina CHIP/Medicaid	$62.55
Rate for Payer: Multiplan Auto	$56.47
Rate for Payer: Multiplan Commercial	$56.47
Rate for Payer: Multiplan Workers Comp	$56.47
Rate for Payer: Parkland Medicaid	$62.55
Rate for Payer: Scott and White EPO/PPO	$43.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.55
Rate for Payer: Superior Health Plan EPO	$11.81

Microfiber Mop Cover With Pocket 8 / Bag 15 / Ca

Facility

$86.87

Hospital Charge Code	993578
Hospital Revenue Code	272
Rate for Payer: Cash Price	$59.07

Microfilter CO2 Sampling & O2 Cannula

Facility

$10.52

Hospital Charge Code	993269
Hospital Revenue Code	270
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$7.57
Rate for Payer: Amerigroup CHIP/Medicaid	$0.95
Rate for Payer: BCBS of TX Blue Advantage	$3.16
Rate for Payer: BCBS of TX Blue Essentials	$3.79
Rate for Payer: BCBS of TX PPO	$4.21
Rate for Payer: Cash Price	$7.15
Rate for Payer: Cigna Medicaid	$7.57
Rate for Payer: Molina CHIP/Medicaid	$7.57
Rate for Payer: Multiplan Auto	$6.84
Rate for Payer: Multiplan Commercial	$6.84
Rate for Payer: Multiplan Workers Comp	$6.84
Rate for Payer: Parkland Medicaid	$7.57
Rate for Payer: Scott and White EPO/PPO	$5.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.57
Rate for Payer: Superior Health Plan EPO	$1.43

Know your out-of-pocket cost for care.

All Charges